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June 2008

Comparison of long-term results of drug-eluting stent and bare metal stent implantation in heart transplant recipients with coronary artery disease.

The aim of the study was to compare long-term results of intracoronary implantation of drug-eluting stents (DES) and bare metal stents (BMS) in patients suffering from transplant coronary artery disease (TxCAD). MATERIAL AND METHODS: We performed a retrospective analysis of all intracoronary stent implantations for TxCAD among subjects with at least one follow-up coronary angiography. We identified 28 sirolimus-eluting DES (n = 17) patients, 24 BMS (n = 13 patients), and both DES and BMS (n = 7 patients) implantations among 23 recipients. Mean follow-up after DES was 14 months and after BMS implantation, 20 months. We compared the occurrence of in-stent restenosis (ISR), and patient survival in the context of risk factors that were identified separately for each stent type. Significance was assessed using the log-rank, chi(2) and Mann-Whitney U test. RESULTS: There were 2 (7%) ISR among DES versus 14 (58%) ISR among BMS (P = .0002) patients, with a longer time of freedom from IRS after DES implantation (P = .022). There were three deaths (18%) among DES, four (31%) with BMS, and one (14%) with DES and BMS (P = NS). Left anterior descending artery was the place of DES implantation in 17 (61%) versus 10 (42%) of BMS cases (P = NS). Risk factor profile was comparable except for a higher age at the time of transplantation (46 +/- 7 vs 41 +/- 6 years; P = .011) and stent implantation (54 +/- 7 vs 49 +/- 6 years; P = .0002) for DES. CONCLUSION: Favorable long-term results of sirolimus-eluting stents over BMS implanted for TxCAD suggested their preferential use in heart transplant recipients.

Transplant Proc. 2007 Nov;39(9):2859-61

Enhanced external counter pulsation (EECP) as a novel treatment for restless legs syndrome (RLS): a preliminary test of the vascular neurologic hypothesis for RLS.

BACKGROUND AND PURPOSE: Enhanced external counter pulsation (EECP) is used to treat angina. With sustained treatment this increases collateral circulation to the coronary arteries as well as to the body as a whole. We found some patients who underwent EECP for angina or congestive heart failure who also coincidentally had severe Restless Legs Syndrome (RLS). Case reports are presented. PATIENTS AND METHODS: Six patients with RLS (1F, 5M, ages 55-80) underwent EECP treatment. All patients were given the International RLS Study Group rating scale for RLS (the IRLS) before and immediately after 35 days of EECP treatment. RESULTS: The average IRLS rating scale score of the six patients before treatment was 28.8 (range 23-35), which indicates frequent and moderate to very severe RLS. After 35 days of EECP treatment the IRLS score was 6 (P<0.03), which indicates clinically insignificant RLS. Long-term follow-up in three patients indicates sustained improvement in all three at 3-6 months after EECP was completed (IRLS score 28.3-3.33). Further follow-up in four patients showed sustained improvement in two patients 1 year after EECP was completed. CONCLUSION: EECP improves RLS symptoms significantly and could be considered as an adjunct treatment for patients with RLS. In some cases, the improvement lasts for months after the course of treatment. In this way EECP is unique and unlike pharmacotherapy which requires continuous daily treatment. Furthermore, our results suggest that decreases in vascular flow influence the peripheral or central nervous system leading to the sensory symptoms of RLS. A larger number of patients studied under blinded conditions is needed to draw further conclusions.

Sleep Med. 2005 Mar;6(2):101-6

An analysis of the efficacy and safety of enhanced external counterpulsation at West Virginia University Hospitals.

A retrospective analysis was conducted of 79 consecutive patients who underwent enhanced external counterpulsation (EECP) at West Virginia University Hospitals during the period of November 1998 to September 2005 to determine its efficacy and safety in treating angina. A chart review and/or phone survey was performed to analyze pertinent clinical data (sublingual nitroglycerin use and angina class) pre and post EECP. A total of 60 (76%) patients who were referred for EECP successfully finished the 35 treatments. Seventy-five percent of the patient population improved at least one angina class after a full course of treatment. Therapy was discontinued due to adverse effects in 12 (15%) patients. Statistically significant improvements in angina class and reduction in anti-angina medications were observed in every co-morbid subgroup analyzed, including patients with peripheral vascular disease, diabetes, hyperlipidemia, hypertension, smoking, Post-MI, and LVEF < 40% (P < .05, Wilcoxon Signed-Rank test). Overall, EECP was effective in improving angina as reflected in a substantial reduction in antiangina medications in 59 (75%) patients.

W V Med J. 2007 May-Jun;103(3):10-2

Enhanced external counterpulsation and future directions: step beyond medical management for patients with angina and heart failure.

Between 25,000 and 75,000 new cases of angina refractory to maximal medical therapy and standard coronary revascularization procedures are diagnosed each year. In addition, heart failure also places an enormous burden on the U.S. health care system, with an estimated economic impact ranging from $20 billion to more than $50 billion per year. The technique of counterpulsation, studied for almost one-half century now, is considered a safe, highly beneficial, low-cost, noninvasive treatment for these angina patients, and now for heart failure patients as well. Recent evidence suggests that enhanced external counterpulsation (EECP) therapy may improve symptoms and decrease long-term morbidity via more than 1 mechanism, including improvement in endothelial function, promotion of collateralization, enhancement of ventricular function, improvement in oxygen consumption (VO2), regression of atherosclerosis, and peripheral training effects similar to exercise. Numerous clinical trials in the last 2 decades have shown EECP therapy to be safe and effective for patients with refractory angina with a clinical response rate averaging 70% to 80%, which is sustained up to 5 years. It is not only safe in patients with coexisting heart failure, but also is shown to improve quality of life and exercise capacity and to improve left ventricular function long-term. Interestingly, EECP therapy has been studied for various potential uses other than heart disease, such as restless leg syndrome, sudden deafness, hepatorenal syndrome, erectile dysfunction, and so on. This review summarizes the current evidence for its use in stable angina and heart failure and its future directions.

J Am Coll Cardiol. 2007 Oct 16;50(16):1523-31

The role of enhanced external counterpulsation in the treatment of angina and heart failure.

As the incidence of angina and heart failure continue to rise, new therapeutic options will be needed to treat patients who remain symptomatic or who are intolerant to current treatment. Enhanced external counterpulsation (EECP) is a noninvasive modality being investigated in both angina and congestive heart failure patients. It has been proven to provide symptomatic benefit in angina patients, but has not been proven to show an increase in life expectancy or decrease in cardiovascular events. EECP in heart failure has been proven to be safe, but its efficacy is still uncertain. The present paper summarizes the current literature on the clinical use of EECP in angina and heart failure.

Can J Cardiol. 2007 Aug;23(10):779-81

A new treatment modality in heart failure enhanced external counterpulsation (EECP).

Heart failure remains a significant health problem in the United States and in the world. Despite a surfeit of recent diagnostic and therapeutic advances, patients with heart failure remain inadequately helped. The overwhelming need for new and better therapies continues to stimulate scientists to investigate new technologies. Over the past several years the use of enhanced external counterpulsation as a treatment for chronic angina has steadily increased. Recently, its potential role in heart failure management has been shown. We review the role of enhanced external counterpulsation in heart failure management as an emerging noninvasive outpatient therapy.

Cardiol Rev. 2004 Jan-Feb;12(1):15-20

Effects of enhanced external counterpulsation on anginal symptoms and improvements in objective measures of myocardial ischaemia.

BACKGROUND: Enhanced external counterpulsation (EECP) is a novel, potentially beneficial adjunct therapy used for angina pectoris. We assessed the efficacy of this method in relieving angina and improving objective measures of myocardial ischaemia. METHODS: All patients (67) who referred for EECP to Shahid Chamran Hospital, Isfahan, Iran from 2002 to 2005 were included. Demographic data, coronary artery disease (CAD) risk factors and baseline angiographic data were collected. Anginal symptoms, Canadian Cardiovascular Society (CCS) functional class, echocardiographic parameters (ejection fraction, left ventricular end-diastolic and end-systolic diameters) and exercise test duration before and after the treatment were compared. RESULTS: Seventy-seven per cent of patients who had undergone EECP had a positive clinical response. Exercise test duration and CCS functional class improved after the treatment. However, EECP had no significant effect on echocardiographic parameters. Efficacy was independent of age, gender, CAD risk factors, prior CCS functional class and echocardiographic parameters. Patients without left main artery involvement and those who had at least one non-obstructed artery demonstrated a greater likelihood of improvement. CONCLUSION: The results of this study suggested that EECP is a safe, well tolerated, and significantly effective treatment for angina pectoris.

Cardiovasc J Afr. 2007 May-Jun;18(3):154-6

Two-year clinical outcomes after enhanced external counterpulsation (EECP) therapy in patients with refractory angina pectoris and left ventricular dysfunction (report from The International EECP Patient Registry).

Enhanced external counterpulsation (EECP) is a noninvasive circulatory assist device that has recently emerged as a treatment option for refractory angina in left ventricular (LV) dysfunction. This 2-year cohort study describes the long-term follow-up of patients who had severe LV dysfunction that was treated with EECP for angina pectoris and reports clinical outcomes, event-free survival rates, and the incidence of repeat EECP. This study included 363 patients who had refractory angina and LV ejection fraction < or =35%. Most patients reported quality of life as poor. After completion of treatment, there was a significant decrease in severity of angina class (p < 0.001), and 72% improved from severe angina to no angina or mild angina. Fifty-two percent of patients discontinued nitroglycerin use. Quality of life improved substantially. At 2 years this decrease in angina was maintained in 55% of patients. The 2-year survival rate was 83%, and the major adverse cardiovascular event-free survival rate was 70%. Forty-three percent had no reported cardiac hospitalization; 81% had no reported congestive heart failure events. Repeat EECP was performed in 20% of these patients. The only significant independent predictor of repeat EECP in a proportional hazard model was failure to complete the first EECP treatment course (hazard ratio 2.9, 95% confidence interval 1.7 to 4.9). Improvements in angina symptoms and quality of life were maintained at 2 years. In conclusion, for patients who have high-risk LV dysfunction, EECP offers an effective, durable therapeutic approach for refractory angina. Decreased angina and improvement in quality of life were maintained at 2 years, with modest repeat EECP and low major cardiovascular event rates.

Am J Cardiol. 2006 Jan 1;97(1):17-20

One year follow-up of patients with refractory angina pectoris treated with enhanced external counterpulsation.

BACKGROUND: Enhanced external counterpulsation (EECP) is a non-invasive technique that has been shown to be effective in reducing both angina and myocardial ischemia in patients not responding to medical therapy and without revascularization alternatives. The aim of the present study was to assess the long-term outcome of EECP treatment at a Scandinavian centre, in relieving angina in patients with chronic refractory angina pectoris. METHODS: 55 patients were treated with EECP. Canadian cardiovascular society (CCS) class, antianginal medication and adverse clinical events were collected prior to EECP, at the end of the treatment, and at six and 12 months after EECP treatment. Clinical signs and symptoms were recorded. RESULTS: EECP treatment significantly improved the CCS class in 79 +/- 6% of the patients with chronic angina pectoris (p < 0.001). The reduction in CCS angina class was seen in patients with CCS class III and IV and persisted 12 months after EECP treatment. There was no significant relief in angina in patients with CCS class II prior to EECP treatment. 73 +/- 7% of the patients with a reduction in CCS class after EECP treatment improved one CCS class, and 22 +/- 7% of the patients improved two CCS classes. The improvement of two CCS classes could progress over a six months period and tended to be more prominent in patients with CCS class IV. In accordance with the reduction in CCS classes there was a significant decrease in the weekly nitroglycerin usage (p < 0.05). CONCLUSION: The results from the present study show that EECP is a safe treatment for highly symptomatic patients with refractory angina. The beneficial effects were sustained during a 12-months follow-up period.

BMC Cardiovasc Disord. 2006 Jun 15;6:28

Impact of external counterpulsation treatment on emergency department visits and hospitalizations in refractory angina patients with left ventricular dysfunction.

Patients with refractory angina and left ventricular (LV) dysfunction exert an enormous burden on health care resources primarily because of the number of recurrent emergency department (ED) visits and hospitalizations. Enhanced external counterpulsation (EECP) therapy has emerged as a treatment option for patients with angina and LV dysfunction and has been shown to improve clinical outcomes and LV function. Improvements in symptoms and laboratory assessments in these patients, however, do not necessarily correlate with a reduction in ED visits and hospitalizations. This is the first study to assess the impact of EECP therapy on ED visits and hospitalization rates at 6-month follow-up. This prospective cohort study included 450 patients with LV dysfunction (ejection fraction <or=40%) treated with EECP therapy for refractory angina. Clinical outcomes, number of all-cause ED visits, and hospitalizations within the 6 months before EECP therapy were compared with those at 6-month follow-up. Despite the unfavorable risk profile, refractory angina patients with LV dysfunction achieved a substantial reduction in all-cause ED visits and hospitalization rates at 6-month follow-up. EECP therapy appears to offer an effective adjunctive treatment option for this group of patients.

Congest Heart Fail. 2007 Jan-Feb;13(1):36-40

Enhanced external counterpulsation improves exercise duration and peak oxygen consumption in older patients with heart failure: a subgroup analysis of the PEECH trial.

The Prospective Evaluation of Enhanced External Counter-pulsation in Congestive Heart Failure (PEECH) trial demonstrated that enhanced external counterpulsation (EECP) therapy increased exercise duration and improved functional status and quality of life without affecting peak oxygen consumption. The authors present data from a prespecified subgroup of elderly patients (65 years or older) enrolled in the PEECH trial. The 2 co-primary end points were the percentage of subjects with a >60-second increase in exercise duration and the percentage of subjects with a >1.25-mL/kg/min increase in peak volume of oxygen consumption. At 6-month follow-up, the exercise responder rate was significantly higher in EECP patients compared with controls (P=.008). Further, in contrast to the overall PEECH study, the EECP group demonstrated a significantly higher responder rate for peak oxygen consumption (P=.017). The authors conclude that an older subgroup of PEECH subjects confirms the beneficial effect of EECP in patients with chronic, stable, mild-to-moderate heart failure.

Congest Heart Fail. 2006 Nov-Dec;12(6):307-11

Enhanced external counterpulsation improves exercise tolerance in patients with chronic heart failure.

OBJECTIVES: The PEECH (Prospective Evaluation of Enhanced External Counter-pulsation in Congestive Heart Failure) study assessed the benefits of enhanced external counterpulsation (EECP) in the treatment of patients with mild-to-moderate heart failure (HF). BACKGROUND: Enhanced external counterpulsation reduced angina symptoms and extended time to exercise-induced ischemia in patients with coronary artery disease, angina, and normal left ventricular function. A small pilot study and registry analysis suggested benefits in patients with HF. METHODS: We randomized 187 subjects with mild-to-moderate symptoms of HF to either EECP and protocol-defined pharmacologic therapy (PT) or PT alone. Two co-primary end points were pre-defined: the percentage of subjects with a 60 s or more increase in exercise duration and the percentage of subjects with at least 1.25 ml/min/kg increase in peak volume of oxygen uptake (VO2) at 6 months. RESULTS: By the primary intent-to-treat analysis, 35% of subjects in the EECP group and 25% of control subjects increased exercise time by at least 60 s (p = 0.016) at 6 months. However, there was no between-group difference in peak VO2 changes. New York Heart Association (NYHA) functional class improved in the active treatment group at 1 week (p < 0.01), 3 months (p < 0.02), and 6 months (p < 0.01). The Minnesota Living with Heart Failure score improved significantly 1 week (p < 0.02) and 3 months after treatment (p = 0.01). CONCLUSIONS: In this randomized, single-blinded study, EECP improved exercise tolerance, quality of life, and NYHA functional classification without an accompanying increase in peak VO2.

J Am Coll Cardiol. 2006 Sep 19;48(6):1198-205

Effects of enhanced external counterpulsation (EECP) on myocardial perfusion.

PURPOSE: To evaluate whether enhanced external counterpulsation (EECP) exerts an effect on myocardial perfusion. METHODS: Eleven patients with angina were studied before and after 35 sessions of EECP treatment. Myocardial perfusion was quantified with positron emission tomography and intravenous 13N-ammonia at rest and after dipyridamole, by means of a two-compartment mathematical model. CONCLUSION: The results suggest that EECP has no effect on myocardial perfusion. However, because of the small number of patients in this study and highly variable clinical responses, additional studies are required to corroborate this finding. The beneficial effects of EECP appear to be mediated by other mechanisms.

Am J Ther. 2007 Nov-Dec;14(6):519-23

An update on enhanced external counterpulsation.

The development of advanced revascularization techniques has resulted in the growth of a subset of patients with coronary artery disease who are nonrevascularizable and are considered to have refractory angina. Enhanced external counterpulsation (EECP) has been developed for the management of these patients with chronic, refractory disease. Evidence has shown that through improvement of vascular endothelial function and recruitment of collateral vessels, EECP provides many clinical benefits. These patients experience sustained decreases in angina, improvement in exercise time, improved myocardial perfusion, and enhanced quality of life. Furthermore, EECP appears to be safe and effective in the treatment of angina in patients with impaired systolic function and has similar potential in patients with congestive heart failure.

Clin Cardiol. 2005 Mar;28(3):115-8

Effect of enhanced external counterpulsation on inflammatory cytokines and adhesion molecules in patients with angina pectoris and angiographic coronary artery disease.

Cardiovascular disease is associated with chronic low-level inflammation, as evidenced by elevated circulating proinflammatory cytokines. Experimental evidence suggests that inflammation can be suppressed under conditions of high shear stress. This study was conducted to examine the effects of enhanced external counterpulsation (EECP), a noninvasive therapy that increases endothelial shear stress, on circulating levels of inflammatory biomarkers and adhesion molecules in patients with angina pectoris. Twenty-one patients were randomly assigned to either 35 1-hour treatments at cuff pressures of 300 mm Hg (EECP; n=12) or 75 mm Hg (sham; n=9). Plasma tumor necrosis factor-alpha, monocyte chemoattractant protein-1, and soluble vascular cell adhesion molecule-1 were measured before and after 35 1-hour sessions of treatment or sham. Patients in the EECP group demonstrated reductions in tumor necrosis factor-alpha (6.9+/-2.7 vs 4.9+/-2.5 pg/ml, p<0.01; -29%) and monocyte chemoattractant protein-1 (254.9+/-55.9 vs 190.4+/-47.6 pg/ml, p<0.01; -19%) after treatment, whereas there was no change in the sham group. Changes in soluble vascular cell adhesion molecule-1 were not observed in either group. In conclusion, 35 sessions of EECP decreased circulating levels of proinflammatory biomarkers in patients with symptomatic coronary artery disease.

Am J Cardiol. 2008 Feb 1;101(3):300-2